The Pulse

Circumcision: back on the table

After decades of being out of fashion, male circumcision is becoming more popular, after reports of its long-term health benefits.

Published 31/01/2008

[Image source: iStockphoto]

If you could go back in time and could roam the African savanna a million years ago, you'd soon spot the hominids  the ancestors of modern-day humans. They'd be the ones standing up.

You'd also notice that just like the other animals, the pre-humans were stark naked. Not only that, none of the males were circumcised.

In those days, a foreskin was important to a man and conferred an evolutionary advantage. It protected the tip of his penis  the exposed glans penis  from dust, sand, insects, and infections.

But it wasn't long before humans invented clothing, which gave comfort, safety and protection from the elements. The genitals were hidden away in stone-age versions of budgie smugglers.

So much for the foreskin  it wasn't needed. Worse than that, it was actually a liability. Trapped inside clothes, themselves often dirty and sweaty, it became unhygienic. The fashion  especially in people living in hot places like Australia, the Pacific Islands, the Middle East, Indonesia, and the Americas  was to remove it.

The practice of removing the foreskin, called circumcision, is now the most frequently performed surgical procedure in the world, says Brian Morris, Professor of Molecular Medical Sciences at the University of Sydney, writing in the journal BioEssays.

The mucosa (the inner lining) of the foreskin is very thin, and doesn't have the defences against injury and infection that normal skin does, he says. A whitish residue of dead cells and other material, called 'smegma', collects under the foreskin and this attracts bacteria and other microorganisms.

So statistically, men who haven't been circumcised are more prone to a wide range of infectious diseases, ranging from thrush, to human papilloma virus, syphilis, HIV, and urinary tract infections. And their female partners are much more likely to get genital herpes, chlamydia, pelvic inflammatory disease and infertility.

Rates of cancer of the penis and prostate are higher in men who have intact foreskins, and rates of cancer of the cervix are higher in their female partners.

A range of other conditions of the penis are more frequent, including inflammatory conditions of the skin, and phimosis, a narrowing of the opening the foreskin that prevents it being retracted and makes sex painful.

There's a one-in-three chance of an uncircumcised man developing one or more of these conditions over his lifetime, says Morris.

That's why circumcision is routine in infant boys in cultures all over the world (Hispanics, Europeans and Asians being a notable exception).

As with any surgical procedure there are risks. In one in 500 circumcisions there's some minor bleeding and in about 1 in 1000, the circumcision needs to be redone. Complications are fewest when it's done between birth and 4 months (though it can be done at any age). Serious complications requiring hospitalisation are rare. Mutilation or loss of the penis, and death, are practically unheard of if the surgeon is competent, says Morris. But the benefits of circumcision far outweigh the risks, he argues.

Falling rates of circumcision

Nevertheless, rates of circumcision have fallen in many Western countries, especially the UK and Australia. In the US, around 60 per cent of boys are circumcised.

Australia's circumcision rates reached much higher levels in the 1950s and 1960s, but began to fall away in the 1970s.

In the 1970s a belief emerged that circumcision was traumatic for the child. It was painful for the child (anaesthetic wasn't routinely used in the 1970s) and the belief then (since discounted) was that it interfered with the parents bonding with the child. Circumcision rates fell to about 10 per cent in the 1980s.

It's risen since then, driven by more widespread awareness of the benefits in preventing HIV and cervical cancer; today about 15 per cent, on average, of Australia male infants are circumcised at birth.

The anti-circumcision lobby

But despite the volume of scientific evidence of its benefits and its increasing (but slow) reacceptance, there's still strong resistance to circumcision from lobby groups, and even from some sections of the health professions.

Anti-circumcision groups argue that it meddles with nature; and that the penis is more sensitive and sex is more pleasurable if the foreskin is left intact. Circumcision is traumatic, they say  it's a form of mutilation and children aren't able to give consent to it. As adults, men may regret having it, they argue.

There's no scientific evidence for any of this, says Morris. Studies have shown for example that sex isn't any less pleasurable or the penis any less sensitive in circumcised men compared to uncircumcised men. Most women prefer a circumcised penis for appearance and hygiene.

But the lobbyists have had an effect on the medical profession and the perceptions of the wider community, he says. Doctors' groups such as the AMA, and the Paediatrics & Child Health Division of the Royal Australasian College of Physicians, are equivocal at best about it, recommending it only when the child has a medical condition obviously requiring it (a child with phimosis, for example), but not actively encouraging it as a routine elective procedure (although the Royal Australasian College of Physicians is currently revising its position).

State government health departments have followed suit. Public hospitals in all states except Queensland no longer offer elective circumcision for infants. What this means is that parents have to find a surgeon and have it done in a private hospital or circumcision clinic, at a cost of several hundred dollars (which makes it too expensive for many financially disadvantaged parents).

Parents' choice

Like childhood vaccination, circumcision is an emotional, polarising issue. But parents aren't getting enough genuine information based on science to enable them to make a rational choice; when they do, studies indicate they're more likely to opt for circumcision.

Who knows, perhaps in another million years, circumcision won't be necessary. A visitor to the future might find the foreskin has disappeared in the human male, dispensed with by natural selection. Until then, parents will have to become more proactive to protect their sons' future health.